Recurance · prevention of future deaths reports
Pre-inquest brief
Missed aortic dissection diagnosis due to atypical presentation
The earlier warning
Andrew Wing · 3 Apr 2020 · Caroline Topping, Surrey
“The chest Xray taken on the 13th January 2019 showed an image which was at least at the upper end of normal and in the context of a differential diagnosis of aortic dissection should have led to a CT Aorta being undertaken.”
What was promised
Stated action 1 · response to Paul Sartori (29 Apr 2021) · stated timescale: 30 June 2021
“The guidance was reviewed on 18" May 2021 by Clinical and Operational leads in NELFT and Barts Health. It has now been submitted to the joint governance and operational group for consideration and sign off at the next session on gh June 2021.”
judiciary.uk/…/2021-0123-Response-from-Royal-London-Hospital-Re…
Stated action 2 · response to Paul Sartori (29 Apr 2021) · stated timescale: none stated
“The Royal College of Emergency Medicine is in the process of finalising a Guideline, based on the limited evidence that is available on the selection of patients for CT scanning. This will be circulated to our 10,000+ members and published on our website for public viewing. It is planned that this will be endorsed by the Royal College of Radiologists, to raise awareness amongst Radiologists.”
judiciary.uk/…/2021-0123-Response-from-Royal-College-of-Emergen…
What recurred
- 29 Apr 2021 · Paul Sartori · Nadia Persaud · Closely related · confidence 0.90 (high)
- 21 Sept 2023 · Chantelle Reed · Samantha Goward · Closely related · confidence 0.86 (high)
The clearest link, quoted from both reports:
Earlier · Andrew Wing · 3 Apr 2020
“The chest Xray taken on the 13th January 2019 showed an image which was at least at the upper end of normal and in the context of a differential diagnosis of aortic dissection should have led to a CT Aorta being undertaken.”
Later · Paul Sartori · 29 Apr 2021
“During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection.”
What happened next
No web check of the stated actions has been published for this chain.